- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $308.72
| Facility | | $308.72 | $308.72 | $308.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.72 / $308.72 / $569.27
| Professional | | $308.72 | $308.72 | $569.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $39.94
| Professional | | $30.00 | $30.00 | $39.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.56 / $399.56 / $779.14
| Professional | | $399.56 | $399.56 | $779.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.52 / $515.52 / $515.52
| Facility | | $515.52 | $515.52 | $515.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.84 / $604.84 / $604.84
| Professional | | $604.84 | $604.84 | $604.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.42 / $463.69 / $769.66
| Facility | | $455.42 | $463.69 | $769.66 |